Funny about Money

The only thing necessary for the triumph of evil is for good men to do nothing. ―Edmund Burke

Gut Instinct…or Doctor Knows Best?

So I remain undecided about whether to start taking the calcium-channel blocker (blood-pressure lowering pills) recently prescribed by Cardiodoc. Gut instinct tells me not to do this! But of course, Cardiodoc is a doctor, and I was brought up by a mother who believed with all her heart that doctor knows best.

In her case, he didn’t…but that’s another story, hm?

Moving on, here is the basis of my skepticism: In 2016 a six-year randomized study of 12,705 patients (published in the New England Journal of Medicine and widely known as the Hope-3 study) showed that the use of blood pressure medications (such as calcium-channel blockers) indeed did lower blood pressure, but that among people with only moderately elevated blood pressure, they did not reduce the incidence of strokes and cardiovascular events compared, over time, with the control group whose members were given a placebo. The use of statins did show a positive benefit in this group, which did not vary by LDL level or risk level.

The evidence is clearest [we are told] in the cholesterol-lowering arm of the trial. For the intermediate risk population tested in HOPE-3, the trial adds to the large amount of “clear evidence” showing the benefit of statins, said Yusuf. In sharp contrast, the blood pressure arm did not find any overall benefit for antihypertensive therapy, though there was a benefit in the prespecified subgroup with the highest blood pressure levels. The benefits of statins, on the other hand, did not vary by LDL level or level of risk.

Results in the blood pressure arm were more complicated. Overall there was no significant difference in clinical outcomes, but there were significant differences based on the prespecified subgroups of blood pressure at baseline. Trial patients with the highest third of blood pressure at baseline (above 143 mm Hg) derived benefit from antihypertensive therapy. For patients in the middle third, antihypertensive therapy had a neutral effect. For patients in the lowest third, antihypertensive therapy had a harmful effect. [My emphasis.]

So what WERE the middle third, first third, bottom third??

The average blood pressure at baseline for the study participants was 138/82 mm Hg. The authors describe “patients who truly had hypertension” as those with systolic pressure of more than 143.5 mm Hg. I’m not finding explicit figures delineating these groups in the published study; however, the Mayo Clinic  lists these:

  • Normal blood pressure. Your blood pressure is normal if it’s below 120/80 mm Hg.
  • Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from 120 to 129 mm Hg and a diastolic pressure below 80 mm Hg. Elevated blood pressure tends to get worse over time unless steps are taken to control blood pressure.
  • Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
  • Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

Depending on the time span, you could place me in the Stage 1 category (in December 2017 my average figures for the month were 132.5/83.3) or in the “Elevated” category (between June 2017 and today, my average blood pressure has been 128.1/77.5). I can push the systolic figure down by 6 or 8 points simply by doing a 20-minute yoga routine or by performing five minutes of deep-breathing exercises. This presumably would put me in the “middle third” of the Hope-3 study’s subjects, most of the time and in the lower third (120-128/<80) some of the time.

Apparently, what the HOPE-3 researchers regard as “intermediate” is significantly higher than that. We have this from them (NEJM):

Observational studies involving persons without cardiovascular disease show a graded increase in risk at systolic blood-pres sure levels above 115 mm Hg. It has been suggested that lowering blood pressure at any level above this value will reduce the risk of cardiovascular events. . . . However, the role of therapy in persons at intermediate risk (defined as an annual risk of major cardiovascular events of approximately 1%) who do not have vascular disease and who have a systolic blood pressure of less than 160 mm Hg (who represent the majority of middle-aged and older persons) remains less clear. We evaluated this question in the HeartOutcomes Prevention Evaluation (HOPE)–3 trial. [My emphasis.]

IMHO, 1 percent per year is not a very  high risk. After 20 years, that would give you about a 20% chance of a stroke or cardiac event. Since most women would start to see this elevation in their 60s, they’d be their 80s before they had a one-in-five chance of an incident. No, 20% is not great. One would prefer better odds. But it’s not an extremely high risk, either.

So what does this mean in real life? For practicing physicians and their patients?

At last we are able to cite reliable ball-park figures from a representative population at intermediate risk of cardiovascular disease. They confirm that statins reduce risk by about a quarter, whatever the starting point, whereas for blood pressure lowering below a systolic of 143, this does not appear to be true over 5-6 years. However, it may be that BP lowering has benefits over a longer period of time, particularly for the risk of heart failure. [My emphasis.]

And further:

However, treating those with lower blood pressure with the combination is not justifiable. Only statins should be used for them, [said Dr. Eva Lonn, one of the researchers; my emphasis.]

Statins have fewer side effects than blood-pressure-lowering medications. In the Hope-3 study, many fewer people discontinued them than those who discontinued antihypertensives. Neverthless, these treatments may be associated with one dreaded side effect: “Cognitive decline was noted in all patients. The primary outcome, processing speed (measured by Digit Symbol Substitution Test [DSST] at study end) for rosuvastatin vs. placebo: 29.1 vs. 29.4 (p = 0.38); for BP lowering vs. placebo: 29.1 vs. 29.4 (p = 0.86); for combination vs. placebo: 29.3 vs. 29.9 (p = 0.63). Any functional impairment for rosuvastatin vs. placebo: 57% vs. 59%, p = 0.89; for BP lowering vs. placebo: 59% vs. 56%, p = 0.19.” [My emphasis.] Appears to be about the same for either class of drug…since many of the subjects were in their 70s, this effect could simply be age-related.

So, the new American Heart Association guidelines make these recommendations:

  • Only prescribing medication for Stage I hypertension if a patient has already had a cardiovascular event such as a heart attack or stroke, or is at high risk of heart attack or stroke based on age, the presence of diabetes mellitus, chronic kidney disease or calculation of atherosclerotic risk (using the same risk calculator used in evaluating high cholesterol).
  • Recognizing that many people will need two or more types of medications to control their blood pressure, and that people may take their pills more consistently if multiple medications are combined into a single pill.

So if you believe this, I should be on a statin, not on a BP lowering med.  Okay, fine…so what is this stuff I have in this bottle of pills here?

The stuff Cardiodoc prescribed, amlodipine besylate, is a calcium-channel blocker, an antihypertensive. It most commonly gifts you with these fine effects:

Y’know…the last time a cardiodoc inflicted one of these drugs on me, it caused such extravagant vertigo that it became unsafe for me to drive my car. And look at this: it causes palpitations: the very symptom that drove me to seek a doctor in the first place!

We  now have determined that my underlying vertigo complaint probably results from inner-ear congestion, which itself probably results from chronic sinus congestion caused by living with two furry dogs in a climate most richly characterized by airborne dust.

The main negative side effect of statins is cataracts. Most people will get cataracts anyway, should we live long enough. Thus I don’t see that as a deal-killer.

But dizziness that could cause me to fall on the hard tile floors or crash my car? Fatigue, swelling of legs and ankles, heart arrhythmia or palpitations, tremors? Yeah, those are deal-killers, in the present circumstances.

Those circumstances being a) it’s unclear that my blood pressure is high enough to justify treatment with drugs at all; and b) the Powers That Be are now recommending a different class of drugs.

Why is the guy  not following AHA guidelines? Is his knowledge out of date? Has something new been reported that I’m not finding? Unknown…but in the absence of other data, I am very skeptical about taking this stuff. I just do not need to cope with another raft of nasty side effects.

A Different Strategy…or Gaming the BP Monitor?

Interestingly, I learned from a friend that you can push your blood pressure readings down by doing some deep-breathing for about three minutes before the machine is turned on.

The day before yesterday I tried this. I’d just raced in the door from a particularly exasperating drive through a round of frustrating and annoying errands. Before even putting anything away, I instantly attached the BP cuff and ran the machine (you’re supposed to sit quietly without moving or speaking for about five minutes before running a test). The result was blood-curdling: 149/93.

Cripes! I should be dead!

Now I do a series of deep, diaphragmatic breaths, as learned from LaMaze and voice classes. After five minutes of this and another minute of normal breathing, I try again…and get a 19-point drop in blood-pressure reading!

Holy crap!

Well, obviously that’s too bizarre to put much stock in.

Restarting minutes later, though, the Omron (which was just checked against Cardiodoc’s machine) showed three consistent measures in a row of 130/86, 131/89, and 131/89.

That is still 18 points below the height to which driving in Phoenix traffic had just driven my blood pressure.

Ohhhkayyyy…  Let’s try that again after the dust settles. An hour later, the machine produced these results:

120/77, pulse 84
124/72, p. 87
116/72, p. 84
Average of the three readings: 120/74, p. 85

And that, folks, ain’t bad for an old bat who’s pushing 73.

Yesterday, I decided to see what would appear after a 20-minute yoga routine. And what did that elicit?

130/83, p. 87
121/77, p. 87
117/78, p. 87

This, after a full meal, 2½ glasses of wine, and a fistful of chocolate chips. The belly was uncomfortably full…and that should push one’s BP figures up markedly.

So what happens if you test after yoga, on an empty stomach? This morning we have the results, obtained while the dogs were hassling around and I was in a rush to get out of the house for a dental appointment:

117/85, p. 84
117/84, p. 79
113/80, p. 77

Doesn’t look like I’m gonna keel over dead very soon, does it?

So I’m not sure what to make of this.

Is it credible, or is it really just a form of gaming the machine? If you did yoga on a regular basis — at least once a day, or maybe even two or three times a day, would your blood pressure drop into the “mildly elevated” or into the “normal” range and stay there most of the time, barring any enraging events?

That, I do not yet know. Yesterday, when the yoga routine was followed by a whole lot of food, readings remained in the “mildly elevated” region a few hours later: average was 126/83.

Today I was unable to test the status after a round-trip to the dentist’s office, an hour in the chair getting my teeth cleaned, and a side-trip to a grocery store, because the minute I sat down to run the Omron machine, a worker showed up at the front door. That person is still here working on a series of minor maintenance tasks, and so it will be another hour or two before I can see what the story is. By then I probably will have had something to eat, which will skew the results some. I guess.

If eating skews results, are the results real?
If deep breathing skews the results, are the results real?
If a short yoga routine skews the results, are the results real?

Those, in my none-too-humble opinion, are the kinds of question that cast doubt on this whole already doubtful affair.

First, it’s doubtful whether the doctors themselves know whether subjecting middle-aged and elder adults to expensive medication (one jar of this stuff goes for $125!!!) does any good. Some researchers think that for some categories of such adults drugging does no good and so (because of the inevitable side effects) actually does harm. And research has shown that one class of drugs, while it does push the numbers down, does exactly nothing to decrease mortality and morbidity rates.

Meanwhile, if you’re looking for something to focus on for your meditation: consider the enormity of the profit that can result from putting every aging Baby-Boomer on drugs that cost $125 a bottle.

Who, really, benefits from this?

Still undecided, then, whether to start gulping these pills.

But my sense is, as usual…

When in doubt, don’t.

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Author: funny

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10 Comments

  1. You can find a summary of the American College of Cardiology’s current recommendations for treating HBP in adults at: http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults.

    A few years ago, the stress of my job was sending my blood pressure into the stratosphere, but I could bring readings back into a still high but much lower range by completing breathing exercises before the reading. My brother, a doctor, would get on me for doing that; however, he said that I needed to do things that would lower my blood pressure over a longer period rather than gaming the test. He recommended dietary changes, weight loss, yoga and/or meditation.

    • Yup, that’s kinda what I suspect. What’s needed is a set of lifestyle improvements/changes that a) relieve stress immediately and b) provide longer-term habits and strategies for good health.

      I did discover that a single, rather brief yoga routine (about 20 minutes) not only knocked down the numbers dramatically but also seemed to create a residual effect that lasted several hours. At 4:00 p.m., around eight or ten minutes after the routine, BP readings were as low as 117/78. At 5:00 p.m., two of the three ratings were 128/86 and 128/87; considering those two readings, the one at around 5:00 p.m. registered two readings (of three) at 125/81 and 122/79. Seems to suggest that pressures drift up (rather than bouncing back) after stress-reducing maneuvers.

      EDIT: I seem to have screwed up the report of those readings. At 4 p.m. that day, readings were 130/83; 121/77; 117/78 (Average: 122.7/79.3). At 5 p.m., they were 131/89, 125/81, 122/79 (Average: 126.3/83). So yes: apparently after you’ve deliberately pushed your BP ratings down with breathing or yoga exercises, it will drift back up over the course of an hour or so.

      This makes me wonder if several short yoga routines performed during the day — say, three or even four — might over time train the body toward lower pressures. Especially if, as you suggest, combined with reasonable weight loss and daily walking, stair-climbing, or bicycling would cause a sustained improvement.

  2. Before you take statins, read this:

    https://www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/statin-side-effects/art-20046013

    I have a relative who experienced muscle damage (rhabdomyolysis) a few months ago as a result of taking statins and has still not fully recovered.

    • Yipes! I spotted that in passing but didn’t register what rhabdomyolysis is: muscle damage that releases a toxin that damages the kidneys! Holy mackerel.

      We won’t be using that stuff, either. Comes under the heading of “cure is worse than the disease,” eh?

  3. Doctors seems a little too anxious to right prescriptions IMHO. I worry about the long term and what it does to your body….and does it make your body dependent on the meds over time. Add to this all the interactions of the drugs and YIKES. I will share that Dear Wife has been on BP meds for some time. Recently she signed up for a yoga class (an hour) and a Zumba class (an hour)….The other day while at one of these classes she discovered that she had not taken her morning pills … it was 2PM and she felt fine. Perhaps exercise is the key….$125 a bottle?….I feel faint!

    • The problem with hypertension is that you feel fine until you have a stroke. That’s why you do need to keep it under control, whether it’s through diet-weight management-exercise or with drugs. Some people are overweight for genetic reasons or because they have some real ailment that leads to weight gain and so have a difficult time keeping into a range that holds the BP more or less under control. Others (like, oh…say…me) get too lazy to get off their duffs and work at it…which is what you have to do as you get older.

  4. Seriously? Amlodipine is $125 a bottle? It’s generic! My husband takes it, at no copay for us, because it’s covered at 100% as an ACA-mandated preventative drug. In my humble opinion, if you’re being charged $125, you’re being royally, big-time screwed. He also takes a statin (also no-copay because it’s preventative). And we have really horrible insurance — its only redeeming feature is the list of no-copay preventative medicines. Or maybe the price is an Arizona thing? I hope you’re able to find it cheaper, should you decide to take it.

    • No, I paid $7.50 for it. My Part D insurer footed the rest of the bill. The paperwork that comes with the Rx states that the retail cost of the prescription — which SOMEBODY paid into Big Pharma’s pocket — is $125.98.

      If indeed that is the case, it doesn’t MATTER whether the sheeple themselves are paying for these drugs. What matters is that the manufacturer is getting it from someone. And that some 60% of Americans supposedly are or will be candidates for blood pressure medication.

      Check this out: https://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319587.pdf The chart at this American Heart Assn site indicates that 63.9% of women and 70.8% of men in the 65-to-74-year-old bracket are hypertensive; among those who survive to age 75 or beyond, 70.2% of women and 80.2% of men.

      This country has 76 MILLION baby boomers out there. And SOMEBODY is paying the tab for their meds.

      The truth is, all of us are: you have to have health insurance — the Democrats would like to mandate it, but even if the Republicans get their way permanently, you’d be nuts not to carry insurance. We all pay for meds through our insurance and our Medicare premiums. So even though I paid a pharmacy $7.50, in fact I pay something like $20 a month for Part D, prescription med coverage — and I have a low-end plan. If you’re under 65, you’re paying MUCH more than that…and that money goes into a pool to cover meds when you — and everyone else — needs them.

      Consider the size of a market like that: 76 MILLION people, the large majority of whom already do or soon will be told to start swallowing a specific type of medication!

      That represents a revenue of $9,500,000,000 for one bottle of said medication. My prescription is enough for 90 days. That’s 1/4 of a year. So if every one of us were on this or a similarly lucrative drug, that represents gross sales of as much as $38,000,000,000 per year. Well…let’s say about 60% of that: a mere $22,800,000,000. And when applied to the Baby Boomer cohort, 60% is just the start: they start out fleecing 60% of us, but within a few years, it’s more like 70%.

      Think of that, if you can. I’m willing to bet you can’t: $22,800,000,000 PER YEAR is beyond our ken, most of us…to say nothing of $38,000,000,000 a year.

      Do you REALLY trust the motives of an industry that stands to gain that much? An industry that aggressively conspired to market a highly addictive class of drugs to doctors and their patients?

      By 2015, that marketing campaign left TWO MILLION Americans addicted, many of them hopelessly, to that industry’s products — and left state and the federal taxpayers holding the expensive bag for their care and for the crime, abuse, and dependency spawned by growing rates of drug addiction. (Check it out: https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf)

      Let us not forget, in this category, the campaign to get every post-menopausal woman on hormones, now believed to foster breast and ovarian cancer. My gynecologist hustled me as hard as he could to go on HRT — well before I hit menopause — telling me (as he had been assured by Big Pharma’s sales reps) that it would not only rescue me from (eeek!) hot flashes but would keep my skin wrinkle-free, my belly flat, my bones strong, and my hair shiny and beautiful.

      Look. When you see a set of circumstances like this AND you see a peer-reviewed, randomized study that says these anti-hypertensive drugs DO NOTHING TO CUT RATES OF STROKE AND CARDIAC EVENTS, you have no choice but to look at the situation skeptically.

      For the love of God, my friends. QUESTION AUTHORITY! Never fail to question authority.

  5. Let me add to that: Speaking of questioning authority, you should read this: https://www.huffingtonpost.com/martha-rosenberg/health-news_b_4398304.html

    The American Heart Assn, a nonprofit, receives MILLIONS of dollars from drug companies. In 2013, a scandal erupted (http://www.nytimes.com/2013/11/18/health/risk-calculator-for-cholesterol-appears-flawed.html?_r=0) when AHA’s online cardiac risk calculator was found to vastly overestimate risk. The organization and its operators have a web of financial ties with the pharmaceutical industry and with food companies claiming to produce “heart-healthy” products. Corporate support in 2015/16 represented 20.8% of its revenues, and support from pharmaceutical companies, 5.8%, according to a self-reporting document (https://www.heart.org/idc/groups/heart-public/@wcm/@fin/documents/downloadable/ucm_491971.pdf).

  6. I think you’re on the right track, and in your circumstances, I don’t think I’d take the meds either. But I’m heavily biased against the pharmaceutical industry and feel doctors are way too heavily influenced by them, so feel free to take my opinion with a grain of salt. (Or no-sodium salt substitute, if you can get past the taste…)